Provider Demographics
NPI:1588965479
Name:DIDOS, SAMIRA GRACE (PHD)
Entity type:Individual
Prefix:DR
First Name:SAMIRA
Middle Name:GRACE
Last Name:DIDOS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 WATERFORD PL
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-6971
Mailing Address - Country:US
Mailing Address - Phone:217-369-7467
Mailing Address - Fax:
Practice Address - Street 1:1503 WATERFORD PL
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-6971
Practice Address - Country:US
Practice Address - Phone:217-369-7467
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071.003660103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical